Assessment of ovarian reserve in women undergoing cystectomy for benign ovarian disease

Ovarian cystectomy is commonly performed to treat benign ovarian cysts, but might cause inadvertent damage to normal ovarian tissue, thereby influencing a woman’s ovarian reserve. Ovarian reserve is defined as the existent quantitative and qualitative supply of follicles which are found in the ovaries that can potentially develop into mature follicles which in effect determine a woman’s reproductive potential. It is commonly quantified by the levels of serum FSH and recently by total antral follicle count (2.0-10.0 mm follicles in both ovaries) and AMH levels. These tests however have inherent biological variation in relation to menstrual cycle and ageing; and are also influenced by the intra- and inter-observer variations. The aim of this thesis was to develop a reliable method of examining the effect of ovarian cystectomy on ovarian reserve. I began by examining the ultrasound markers of ovarian reserve. AFC is measured using 2D ultrasound and there is some evidence that 3D ultrasound can make more reliable counts than 2D. I examined the reliability of these two methods and compared them to a new 3D assisted method, SonoAVC which is designed to make automated AFC. I found that the intra- and inter-observer reliability of SonoAVC in counting the number of antral follicles was superior to 2D and 3D manual methods. It however required post-processing of the counts by manually clicking on the antral follicles initially missed in the automated version, thereby making it a semi-automated method. I then compared 2D ultrasound to SonoAVC in measuring the size of antral follicles as there is increasing evidence that the small antral follicles might be more predictive of ovarian reserve. I found that SonoAVC measured the size of antral follicles significantly quicker than 2D and also that the number of small follicles measured by 2D were more than SonoAVC, thereby raising the possibility that 2D might overestimate the number of small antral follicles. I then studied the ability of antral follicle counts stratified by size in prediction of ovarian response and pregnancy. I found that the small antral follicles measuring between 2.0-4.0 mm were independent predictors of clinical pregnancy and ovarian response to assisted reproduction treatment. I then examined the AFCs of different sizes made by SonoAVC and 2D in bovine ovaries and compared to the follicles obtained by manually dissecting the follicles. I found that SonoAVC with post-processing significantly underestimated and 2D overestimated the number of antral follicles measuring 4.0mm or less, but both made comparable counts of follicles measuring more than 4.0mm when compared with the antral follicles dissected manually. However, the agreement with SonoAVC with post-processing was more than that with 2D. Having established that SonoAVC albeit with post-processing was the most reliable method in measuring the size of antral follicles, I began to examine the intra- and inter-cycle variation and compared to AMH. I found that the small antral follicle measuring 2.0-6.0 mm showed least intra-and inter-cycle variation and that it was comparable to AMH. The larger antral follicles showed significant intra-cycle variation but a non-significant inter-cycle variation in the early follicular phase of menstrual cycle. I also examined the inter-ovarian variation in the AFC’s and found that the small antral follicles measuring 2.0-6.0 mm again showed the least variation between ovaries within an individual. I was finally able to conclude that small antral follicles (≤6.0mm) measured using SonoAVC were the most reliable in prediction of ovarian reserve, and showed excellent correlation with AMH. Finally, I examined the effect of laparoscopic ovarian cystectomy on the ovarian reserve for up to 6 months post-operatively using AMH and small AFC measured by SonoAVC. I found that ovarian cystectomy significantly reduces ovarian reserve and that this effect may be more pronounced with cysts of endometriotic nature, followed by dermoid cysts. In summary, the effect of ovarian cystectomy on ovarian reserve is best quantified using AFC of small follicles measuring less than 6.0 mm as it provides reliable measures of ovarian reserve, has minimal biological variation and is comparable to AMH

Assessment of ovarian reserve in women undergoing cystectomy for benign ovarian disease

Ovarian cystectomy is commonly performed to treat benign ovarian cysts, but might cause inadvertent damage to normal ovarian tissue, thereby influencing a woman’s ovarian reserve. Ovarian reserve is defined as the existent quantitative and qualitative supply of follicles which are found in the ovaries that can potentially develop into mature follicles which in effect determine a woman’s reproductive potential. It is commonly quantified by the levels of serum FSH and recently by total antral follicle count (2.0-10.0 mm follicles in both ovaries) and AMH levels. These tests however have inherent biological variation in relation to menstrual cycle and ageing; and are also influenced by the intra- and inter-observer variations. The aim of this thesis was to develop a reliable method of examining the effect of ovarian cystectomy on ovarian reserve. I began by examining the ultrasound markers of ovarian reserve. AFC is measured using 2D ultrasound and there is some evidence that 3D ultrasound can make more reliable counts than 2D. I examined the reliability of these two methods and compared them to a new 3D assisted method, SonoAVC which is designed to make automated AFC. I found that the intra- and inter-observer reliability of SonoAVC in counting the number of antral follicles was superior to 2D and 3D manual methods. It however required post-processing of the counts by manually clicking on the antral follicles initially missed in the automated version, thereby making it a semi-automated method. I then compared 2D ultrasound to SonoAVC in measuring the size of antral follicles as there is increasing evidence that the small antral follicles might be more predictive of ovarian reserve. I found that SonoAVC measured the size of antral follicles significantly quicker than 2D and also that the number of small follicles measured by 2D were more than SonoAVC, thereby raising the possibility that 2D might overestimate the number of small antral follicles. I then studied the ability of antral follicle counts stratified by size in prediction of ovarian response and pregnancy. I found that the small antral follicles measuring between 2.0-4.0 mm were independent predictors of clinical pregnancy and ovarian response to assisted reproduction treatment. I then examined the AFCs of different sizes made by SonoAVC and 2D in bovine ovaries and compared to the follicles obtained by manually dissecting the follicles. I found that SonoAVC with post-processing significantly underestimated and 2D overestimated the number of antral follicles measuring 4.0mm or less, but both made comparable counts of follicles measuring more than 4.0mm when compared with the antral follicles dissected manually. However, the agreement with SonoAVC with post-processing was more than that with 2D. Having established that SonoAVC albeit with post-processing was the most reliable method in measuring the size of antral follicles, I began to examine the intra- and inter-cycle variation and compared to AMH. I found that the small antral follicle measuring 2.0-6.0 mm showed least intra-and inter-cycle variation and that it was comparable to AMH. The larger antral follicles showed significant intra-cycle variation but a non-significant inter-cycle variation in the early follicular phase of menstrual cycle. I also examined the inter-ovarian variation in the AFC’s and found that the small antral follicles measuring 2.0-6.0 mm again showed the least variation between ovaries within an individual. I was finally able to conclude that small antral follicles (≤6.0mm) measured using SonoAVC were the most reliable in prediction of ovarian reserve, and showed excellent correlation with AMH. Finally, I examined the effect of laparoscopic ovarian cystectomy on the ovarian reserve for up to 6 months post-operatively using AMH and small AFC measured by SonoAVC. I found that ovarian cystectomy significantly reduces ovarian reserve and that this effect may be more pronounced with cysts of endometriotic nature, followed by dermoid cysts. In summary, the effect of ovarian cystectomy on ovarian reserve is best quantified using AFC of small follicles measuring less than 6.0 mm as it provides reliable measures of ovarian reserve, has minimal biological variation and is comparable to AMH

Mutant p53 establishes targetable tumor dependency by promoting unscheduled replication

Gain-of-function (GOF) p53 mutations are observed frequently in most intractable human cancers and establish dependency for tumor maintenance and progression. While some of the genes induced by GOF p53 have been implicated in more rapid cell proliferation compared with p53-null cancer cells, the mechanism for dependency of tumor growth on mutant p53 is unknown. This report reveals a therapeutically targetable mechanism for GOF p53 dependency. We have shown that GOF p53 increases DNA replication origin firing, stabilizes replication forks, and promotes micronuclei formation, thus facilitating the proliferation of cells with genomic abnormalities. In contrast, absence or depletion of GOF p53 leads to decreased origin firing and a higher frequency of fork collapse in isogenic cells, explaining their poorer proliferation rate. Following genome-wide analyses utilizing ChIP-Seq and RNA-Seq, GOF p53–induced origin firing, micronuclei formation, and fork protection were traced to the ability of GOF p53 to transactivate cyclin A and CHK1. Highlighting the therapeutic potential of CHK1’s role in GOF p53 dependency, experiments in cell culture and mouse xenografts demonstrated that inhibition of CHK1 selectively blocked proliferation of cells and tumors expressing GOF p53. Our data suggest the possibility that checkpoint inhibitors could efficiently and selectively target cancers expressing GOF p53 alleles

Evaluating the impact of the reconfiguration of gynaecology services at a University Hospital NHS trust in the United Kingdom

Background: The project aim was to investigate the impact of reconfiguring gynaecology services on the keyperformance indicators of a University Hospital NHS Trust in the UK. The reconfiguration involved the centralisationof elective gynaecology on one hospital site and emergency gynaecology on the other.Methods: Data measuring outcomes of the Trust’s performance indicators (clinical outcomes, patient experience,staff satisfaction, teaching/training, research/development and value for money) were collected. Two time periods,12 months before and after the reconfiguration in March 2011, were compared for all outcome measures exceptpatient experience. Retrospective data from the hospitals audit department on clinical activity/outcomes andemergency gynaecology patient’s feedback questionnaires were analysed. Staff satisfaction, teaching/training andresearch/development were measured through an online survey of gynaecology consultants.Results: Post reconfiguration, the total number of admissions reduced by 6% (6,867 vs 6,446). There was a 14%increase in elective theatre sessions available (902.29 vs 1030.57) and an 84% increase in elective theatre sessionscancelled (44.43 vs 81.71). However, the average number of elective operations performed during each theatresession remained similar (2.63 vs 2.5). There was a significant increase in medical devices related clinical incidents(2 vs 11). With patient experience, there was a significant reduction in patient’s overall length of stay on theemergency gynaecology ward and waiting times for investigations. For staff satisfaction, Consultants weresignificantly more dissatisfied with workload (3.45 vs 2.85) and standards of care (3.75 vs 2.93). With research anddevelopment, consultants remained dissatisfied with time/funding/opportunities for research. No significantimpact on undergraduate/postgraduate teaching was found. No financial data on gynaecology was provided forthe assessment of value for money.Conclusions: Reconfiguration of gynaecology services at this Trust may have resulted in a reduction ingynaecological activity and increased cancellation of elective operations but did not significantly reduce thenumber of elective operations performed. Although consultants expressed increased dissatisfaction withstandards of clinical care, clinical incident reports did not significantly increase apart from medical devicesincidents. Patient experience of emergency gynaecology services was improved. This manuscript provides aframework for similar exercises evaluating the impact of service redesign in the NHS

Impact of IRS: Four-years of entomological surveillance of the Indian Visceral Leishmaniases elimination programme

BACKGROUND In 2005, Bangladesh, India and Nepal agreed to eliminate visceral leishmaniasis (VL) as a public health problem. The approach to this was through improved case detection and treatment, and controlling transmission by the sand fly vector Phlebotomus argentipes, with indoor residual spraying (IRS) of insecticide. Initially, India applied DDT with stirrup pumps for IRS, however, this did not reduce transmission. After 2015 onwards, the pyrethroid alpha-cypermethrin was applied with compression pumps, and entomological surveillance was initiated in 2016. METHODS Eight sentinel sites were established in the Indian states of Bihar, Jharkhand and West Bengal. IRS coverage was monitored by household survey, quality of insecticide application was measured by HPLC, presence and abundance of the VL vector was monitored by CDC light traps, insecticide resistance was measured with WHO diagnostic assays and case incidence was determined from the VL case register KAMIS. RESULTS Complete treatment of houses with IRS increased across all sites from 57% in 2016 to 70% of houses in 2019, rising to >80% if partial house IRS coverage is included (except West Bengal). The quality of insecticide application has improved compared to previous studies, average doses of insecticide on filters papers ranged from 1.52 times the target dose of 25mg/m2 alpha-cypermethrin in 2019 to 1.67 times in 2018. Resistance to DDT has continued to increase, but the vector was not resistant to carbamates, organophosphates or pyrethroids. The annual and seasonal abundance of P. argentipes declined between 2016 to 2019 with an overall infection rate of 0.03%. This was associated with a decline in VL incidence for the blocks represented by the sentinel sites from 1.16 per 10,000 population in 2016 to 0.51 per 10,000 in 2019. CONCLUSION Through effective case detection and management reducing the infection reservoirs for P. argentipes in the human population combined with IRS keeping P. argentipes abundance and infectivity low has reduced VL transmission. This combination of effective case management and vector control has now brought India within reach of the VL elimination targets

A Randomized Trial of Progesterone in Women with Bleeding in Early Pregnancy

BACKGROUND Bleeding in early pregnancy is strongly associated with pregnancy loss. Progesterone is essential for the maintenance of pregnancy. Several small trials have suggested that progesterone therapy may improve pregnancy outcomes in women who have bleeding in early pregnancy. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial to evaluate progesterone, as compared with placebo, in women with vaginal bleeding in early pregnancy. Women were randomly assigned to receive vaginal suppositories containing either 400 mg of progesterone or matching placebo twice daily, from the time at which they presented with bleeding through 16 weeks of gestation. The primary outcome was the birth of a live-born baby after at least 34 weeks of gestation. The primary analysis was performed in all participants for whom data on the primary outcome were available. A sensitivity analysis of the primary outcome that included all the participants was performed with the use of multiple imputation to account for missing data. RESULTS A total of 4153 women, recruited at 48 hospitals in the United Kingdom, were randomly assigned to receive progesterone (2079 women) or placebo (2074 women). The percentage of women with available data for the primary outcome was 97% (4038 of 4153 women). The incidence of live births after at least 34 weeks of gestation was 75% (1513 of 2025 women) in the progesterone group and 72% (1459 of 2013 women) in the placebo group (relative rate, 1.03; 95% confidence interval [CI], 1.00 to 1.07; P=0.08). The sensitivity analysis, in which missing primary outcome data were imputed, resulted in a similar finding (relative rate, 1.03; 95% CI, 1.00 to 1.07; P=0.08). The incidence of adverse events did not differ significantly between the groups. CONCLUSIONS Among women with bleeding in early pregnancy, progesterone therapy administered during the first trimester did not result in a significantly higher incidence of live births than placebo. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment program; PRISM Current Controlled Trials number, ISRCTN14163439. opens in new tab.

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals <1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

Serum concentrations of Ang-2 and Flt-1 may be predictive of pregnancy outcome in women with pregnancies of uncertain viability: a phase I exploratory prognostic factor study

The aim of this study was to determine whether serum concentrations of Ang-1, Ang-2, Flt-1, IL-15 and/or TRAIL can be used to predict outcome in women with pregnancies of uncertain viability (PUVs). Women presenting to the Early Pregnancy Unit at the Queen’s Medical Centre in Nottingham between 17.06.14 and 01.09.15 were prospectively recruited. Serum concentrations of Ang-1, Ang-2, Flt-1, IL-15 and TRAIL were measured in women with PUVs. Women were followed-up according to departmental protocols until viability was determined. Biomarker concentrations were correlated with pregnancy outcome. Ninety-four PUVs were studied, of which 61 (64.9%) were subsequently proven to be viable. There were statistically significant (p < .01), linear (p-valuetrend <.01) associations between Ang-2 and Flt-1 concentrations and pregnancy viability such that women with lower concentrations were significantly more likely to have viable pregnancies than women with higher concentrations. In conclusion, Ang-2 and Flt-1 may be useful in predicting outcome in women with PUVs.Impact statement What is already known on this subject: Predicting outcome in women with pregnancies of uncertain viability (PUVs) is challenging. There is currently no accurate and reliable method. All PUVs need to be followed-up until a definitive diagnosis of either a viable or non-viable pregnancy can be made. This takes time, utilises limited resources and generates significant anxiety. Recent studies have demonstrated serum concentrations of Ang-1, Ang-2, Flt-1, IL-15 and TRAIL in viable pregnancies are significantly different to those in non-viable or ectopic pregnancies. What the results of this study add: The results from this prospective study of 94 women with PUVs suggest that serum concentrations of Ang-2 and Flt-1 may be able to predict pregnancy viability in cases of uncertainty. Women with PUVs and low concentrations of Ang-2 or Flt-1 are significantly more likely to have viable pregnancies than women with high concentrations. What the implications are of these findings for clinical practice and/or further research: Evidence from multiple studies is necessary to appreciate the discriminating ability of these prognostic factors. Rapid clinical adoption in the absence of such evidence may lead to wasted resources. If our findings are confirmed, however, these biomarkers, either alone or as part of a prognostic model, may be capable of accurately predicting pregnancy outcome in cases of uncertainty. This would reduce the strain on limited resources and alleviate anxiety for women

Evaluating the role of imprint cytology compared to histopathology in the diagnosis of ovarian tumors

Background: Imprint cytology is one of the techniques to evaluate intraoperative pathological diagnosis. It gives quick results and is very cost effective. The morphology is well preserved, and it is very useful for differentiating between benign and malignant lesions intraoperatively. Objective: To evaluate the diagnosis of ovarian tumors in imprint cytology and to correlate it with histopathology and assess its diagnostic accuracy for its future potential application. Materials and Methods: Imprint smears for cytology were made immediately after the gross specimen was received in the department in normal saline.Then the specimen was fixed in 10% buffered formalin and grossed for histopathological examination following standard protocols. After histopathology diagnosis, its correlation was done with the diagnosis of imprint cytology. Results: A total of 50 cases of ovarian lesions were studied.Out of these 50 cases the accuracy for benign lesionswas found to be 88.6%, 25% for borderline cases and 100% for malignant ones. Conclusion: Imprint cytology gives a rapid diagnosis and the high accuracyfor benign and malignant lesions. Considering the findings of the index study, it can be concluded that imprint cytology may be used intraoperatively in doubtful cases for a better surgical outcome in patients